Beliefs About Anal Cancer among HIV-Infected Women: Barriers and Motivators to Participation in Research.

BACKGROUND: Infection with the human immunodeficiency virus (HIV) remains associated with a greater risk of anal cancer, despite widespread use of combination antiretroviral therapy. Evidence concerning the acceptability of anal cancer screening gives little attention to women. Because HIV-infected women have a high prevalence of depression and history of sexual trauma, understanding acceptability among this group is critical. PURPOSE: We sought to assess barriers and motivators to participation in anal cancer screening research among a racial/ethnically diverse HIV-infected female population. METHODS: We conducted a survey based on the Health Belief Model to identify characteristics of women willing to participate in anal cancer screening research (n = 200). Bivariate analyses examined associations between willingness to participate and sociodemographics, clinical characteristics, and health beliefs. Logistic regression modeled willingness to participate in research. MAIN FINDINGS: Of the women who participated, 37% screened positive for depression, 43% reported a high trauma history, and 36% screened positive for posttraumatic stress disorder. Overall, 65% reported willingness to participate in research. Those likely to participate were older, reported intravenous drug use as their HIV risk factor, and had a history of prior high-resolution anoscopy (HRA) compared with those unwilling to participate. The most commonly reported barrier to anal Pap testing was fear of pain. In adjusted analyses, a lack of fear of pain and prior experience with HRA significantly predicted willingness to participate. CONCLUSIONS: Findings suggest that, to increase participation in anal Pap and HRA-related research for HIV-infected women, a single approach may not be adequate. Rather, we must harness patients' previous experiences and address psychosocial and financial concerns to overcome barriers to participation.

Feasibility of patient navigation in resident primary care practice: a screening mammography quality improvement initiative.

Patient navigation (PN) has been used to improve breast cancer outcomes but has not been evaluated in resident practices. The objective of this study was to evaluate the feasibility of PN in resident clinics to improve biennial screening mammography. All participants whose last screening mammogram was at 18 months or after received PN. Feasibility outcomes included practicality (ability to carry out intervention), effectiveness (ability of intervention to increase biennial screening mammography rates), and acceptability (resident satisfaction with PN). Despite difficulty contacting patients, we found PN improved screening mammography adherence in resident practices serving vulnerable populations. Adherence rates increased significantly postintervention. Residents reported interest in using PN in practice.

Challenges in the delivery of quality breast cancer care: initiation of adjuvant hormone therapy at an urban safety net hospital.

PURPOSE: Breast cancer treatment disparities in racial/ethnic minority and low-income populations are well documented; however, underlying reasons remain poorly understood. This study sought to identify barriers to the delivery of quality breast cancer treatment, addressing compliance with the National Quality Forum (NQF) quality metric for adjuvant hormone therapy (HT; administration of HT within 365 days of diagnosis in eligible patients) at an urban safety net hospital. METHODS: This retrospective, observational study included women diagnosed with nonmetastatic, T1c or greater, estrogen and/or progesterone receptor-positive breast cancer from 2006 to 2008. Data sources included the hospital cancer registry and electronic medical record. Compliance with the NQF quality metric was defined as HT prescription within 365 days of diagnosis. Bivariate analysis compared compliant with noncompliant patients. Qualitative analysis assessed reasons for delayed compliance (HT at > 365 days) and never compliance (no HT at 4 years). RESULTS: Of 113 eligible patients, the majority were racial/ethnic minority (56%), stage II (54%), unmarried (60%), and had public or no insurance (72%). Sixty-four percent were compliant, and 36% were noncompliant. Of the noncompliant, 78% had delayed compliance, and 22% were never compliant. Noncompliant patients were significantly more likely to be Black, Hispanic, foreign-born, and stage III at diagnosis. Ten reasons for delayed compliance were identified, including patient- and system-level barriers. Most patients (56%) had more than one reason contributing to delay. CONCLUSION: Urgently needed interventions to reduce disparities in breast cancer treatment should take into account obstacles inherent among immigrant and indigent populations and complexities of multidisciplinary cancer care.

Adherence to conservative management recommendations for abnormal pap test results in adolescents.

OBJECTIVE: To investigate whether the 2006 American Society for Colposcopy and Cervical Pathology guidelines for conservative management of minimally abnormal Pap test results (atypical squamous cells of undetermined significance, human papillomavirus-positive, and low-grade squamous intraepithelial lesions) and moderate dysplasia (cervical intraepithelial neoplasia 2) in adolescents 1) resulted in fewer colposcopies and loop electrosurgical excision procedures (LEEPs) in adolescents or 2) resulted in unintended treatment changes in older age groups. METHODS: We analyzed data from 1,806 women aged 18 years and older attending one of six community health centers who were diagnosed with abnormal Pap test results between January 1, 2004, and December 31, 2008. We used multivariable logistic regression to examine treatment differences in women with minimally abnormal Pap test results before and after guideline changes. Variables included date of abnormality, site of care, race or ethnicity, language, and insurance type. We used Fisher exact tests to examine rates of LEEP in patients with moderate dysplasia before and after guideline publication. RESULTS: Among 206 women aged 18-20 years, rates of colposcopy after a minimally abnormal Pap test result decreased from 78% (n=102) to 45% (n=34) after guideline changes (P<.001). Colposcopy among women over age 21 (n=1,542) remained unchanged (greater than 90%). Multivariable logistic regression indicated that both date of abnormality and site of care were associated with colposcopy referral. After guideline changes, management of moderate dysplasia with LEEP in women aged 18-23 decreased from 55% to 18% (P=.04); rates remained stable in women ages 24 and older (70% compared with 74%; P=.72). CONCLUSION: Health care providers quickly adopted new conservative management guidelines for low-income, minority adolescents, which may reduce preterm deliveries in these high-risk populations. LEVEL OF EVIDENCE: II.